Webster Park Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Webster Park Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 13, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who had no pressure injuries at time of admission to the Facility, was assessed by nursing to be at high risk for the development of a pressure injury, and whose Hospital Discharge Summary indicated physicians orders for the removal of his/her left knee immobilizer brace twice daily for skin checks, the Facility failed to ensure adequate measures were implemented by nursing to maintain his/her skin integrity to prevent the development of a pressure injury after admission. […]

• Actual harm, isolatedF760Aug 31, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted to the Facility, and whose physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was not administered his/her physician ordered [MEDICATION(S)], experienced a stroke, required transfer to the Hospital Emergency Department for further evaluation and was admitted . Finding includes: Review of the Facility's Policy titled, Reconciliation of Medications on Admission, undated, indicated the following: -gather information needed to reconcile the medication list using the discharge summary from referring facility; -list all medications from the discharge summary; -list the dose, route and frequency for all medications; -review the list carefully to determine if there… […]

• No harm, potential for more than minimal, widespreadF880Oct 31, 2023

  Based on document review, policy review, and interviews, the facility failed to maintain an infection prevention and control program with a complete and accurate system of surveillance to identify any trends of actual or potential infections within the facility using their predetermined infection definition criteria. Findings include: Review of the facility's policy titled Surveillance of Infections, dated as revised September 2017, indicated but was not limited to the following: - The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections to guide appropriate interventions and prevent future infections. […]

• No harm, potential for more than minimal, patternF552Jan 28, 2025

  Based on record review and interviews, the facility failed to ensure for one Resident (#15), out of a total sample of 21 residents, that the Resident's legal guardian (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated) was informed of a change in skin condition by the physician or other practitioner or professional, informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he/she preferred. […]

• No harm, potential for more than minimal, patternF585Jan 28, 2025

  Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 14 of 14 residents attending the resident group meeting during the facility survey, the facility failed to ensure residents were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s). Findings include: Review of the facility's policy titled Grievance and Complaint Procedure, dated January 2022, indicated but was not limited to: -Upon admission, residents are provided with written information on how to file a grievance or complaint within the facility. […]